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General NPI Number Information
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NPI Number | 1558394510
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Entity Type | Individual
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Provider Name | SHAYNA MANCUSO D.O.
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Gender | Female
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Dates
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Enumeration Date | 07/09/2006
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Last Update Date | 10/30/2020
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Provider Practice Location Address
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Address Line | 660 N WESTMORELAND RD
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City | LAKE FOREST
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State | IL
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Zip | 60045
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Country | US
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Telephone | 847-535-6352
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Fax |
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Provider Business Mailing Address
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Address Line | 811 S RIDGE RD
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City | LAKE FOREST
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State | IL
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Zip | 60045-2755
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Country | US
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Telephone | 312-399-1732
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 036-112082
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License Number State | IL
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